What preoperative anesthetic management steps should be taken for abdominal aortic aneurysm repair in a typical high‑risk male patient over 65 years old with hypertension, coronary artery disease, peripheral vascular disease, chronic obstructive pulmonary disease, and possible renal insufficiency?

Preoperative Anesthetic Management for Abdominal Aortic Aneurysm Repair

All patients with coronary artery disease undergoing AAA repair must receive perioperative beta-adrenergic blocking agents unless contraindicated, as this is the single most evidence-based intervention to reduce perioperative cardiac mortality. 1, 2

Cardiac Risk Stratification and Optimization

Mandatory Cardiac Evaluation

• Patients over 40 years or with any history of myocardial infarction, angina, or heart failure symptoms require preoperative 12-lead electrocardiography and transthoracic echocardiography. 2
• Calculate the Lee Revised Cardiac Risk Index; if score ≥2 with functional capacity <4 METs (unable to climb two flights of stairs), refer to cardiology for stress testing before major surgery. 3
• Pharmacologic stress testing is indicated for patients with clinical markers of serious coronary disease who cannot perform standard exercise testing. 4

When to Perform Coronary Angiography

• Only perform preoperative coronary angiography in patients with unstable or severely symptomatic heart disease or those with prior coronary artery bypass grafting. 1
• Do not delay surgery for extensive cardiac workup in stable patients, as this delay is potentially dangerous. 1

Beta-Blocker Administration

• Initiate beta-blockers preoperatively in all patients with known coronary artery disease to reduce adverse cardiac events and mortality (Class I, Level A evidence). 1
• Continue beta-blockers throughout the perioperative period without interruption. 1

Pulmonary Assessment and Optimization

Risk Stratification

• All patients with smoking history or chronic obstructive pulmonary disease require preoperative pulmonary function tests and arterial blood gas analysis for risk stratification. 1
• History of smoking and chronic pulmonary disease are the most important predictors of postoperative respiratory complications. 1

Preoperative Optimization

• Administer bronchodilators when reversible airway obstruction is present. 1
• Prescribe antibiotics if excessive sputum production is documented. 1
• Mandate smoking cessation and offer intensive cessation interventions including behavior modification, nicotine replacement, or bupropion. 1

Renal Protection Strategy

Preoperative renal dysfunction is the single most important predictor of acute renal failure after aortic surgery. 1

Mandatory Measures

• Ensure adequate preoperative hydration in all patients. 1
• Measure baseline serum creatinine and calculate estimated glomerular filtration rate. 1
• Plan intraoperative and postoperative strategies to avoid hypotension, low cardiac output, and hypovolemia. 1, 2

Cerebrovascular Assessment

• Perform duplex imaging of carotid arteries in patients with history of stroke, transient ischemic attack, or other cerebrovascular disease risk factors. 1
• Consider angiography of brachiocephalic arteries to determine stroke risk magnitude, though efficacy of treating significant carotid stenosis prior to AAA repair lacks randomized trial evidence. 1

Anesthetic Technique Selection

For Endovascular AAA Repair (EVAR)

Local anesthesia with sedation is the preferred technique for EVAR when feasible, as it reduces mortality risk by 73% compared to general anesthesia (adjusted OR 0.27; 95% CI 0.1-0.7). 2

For Open AAA Repair

• General anesthesia with comprehensive hemodynamic monitoring is mandatory (Class I, Level C). 1, 2
• Tailor anesthetic agents and monitoring techniques to individual patient needs to facilitate surgical technique and organ function monitoring. 1

Intraoperative Monitoring Plan

Transesophageal Echocardiography

• TEE is reasonable for all open aortic repairs unless specific contraindications exist (Class IIa, Level B). 1, 2
• Consider TEE during endovascular procedures for procedural guidance and endoleak detection. 1, 2

Neurophysiologic Monitoring

• Motor or somatosensory evoked potential monitoring can be useful when data will guide intraoperative therapy decisions (Class IIa, Level B). 1, 2
• Base the decision on individual patient needs, institutional resources, procedure urgency, and surgical technique employed. 1

Hemodynamic Management Strategy

Blood Pressure Targets

• Maintain systolic blood pressure within 10% of baseline throughout the perioperative period to prevent myocardial ischemia and reduce delirium risk. 2, 3
• Avoid hypotension, which directly reduces coronary perfusion and increases acute renal failure risk. 1, 2
• Prevent tachycardia, as it increases myocardial oxygen demand and reduces diastolic coronary perfusion time. 3

Special Consideration for Ruptured AAA

In ruptured AAA, maintain permissive hypotension targeting systolic blood pressure 60-90 mmHg (sufficient for mentation) until definitive surgical control to reduce bleeding. 2

Management of High-Risk Patients

For patients with severe cardiac, pulmonary, or renal disease, endovascular repair under local anesthesia provides the most favorable risk-benefit profile, though overall benefit remains uncertain (Class IIb, Level B). 1, 2

Risk Stratification

• Approximately one in three high-risk patients will experience serious postoperative complications, most commonly cardiac events. 4
• Despite increased operative risk, patients with stable medical conditions and AAA ≥6 cm should be considered for elective repair. 4

Critical Pitfalls to Avoid

• Never induce general anesthesia for ruptured AAA without adequate resuscitation and surgical readiness, as loss of catecholamine response causes immediate circulatory collapse. 2
• Never perform aggressive fluid resuscitation before proximal aortic control in ruptured AAA, as this increases bleeding and mortality. 2
• Do not delay surgery for coronary angiography unless the patient has unstable coronary disease requiring intervention. 1
• Ensure beta-blocker administration is not overlooked in patients with coronary artery disease, as this is the highest-level evidence intervention for mortality reduction. 1, 2

Preoperative Laboratory Testing

• Obtain complete blood count, comprehensive metabolic panel including renal function, coagulation studies, and type and crossmatch. 5
• Perform electrocardiography in all patients and compare with prior tracings to evaluate for new ischemic changes, arrhythmias, or QTc prolongation >440 ms. 2, 3
• Measure arterial blood gases in patients with chronic obstructive pulmonary disease for risk stratification. 1